Low- versus high-dose radiotherapy for Graves' ophthalmopathy: a randomized, single blind trial.

Orbital radiotherapy (Rx) is a commonly used treatment for Graves' ophthalmopathy (GO), but controlled clinical trials evaluating different Rx doses and application forms have not been performed. In euthyroid patients with moderately severe GO, we randomly compared the efficacy and tolerability of three Rx protocols. Orbital Rx (telecobalt) was administered either in 20 divided fractions of 1 Gray (Gy) weekly over 20 weeks (group A) or in 10 fractions of 1 Gy (B) and 2 Gy (C) daily over 2 weeks. Before and 24 weeks after starting Rx, ophthalmic investigation and magnetic resonance imaging were performed. Response to therapy, defined as a significant amelioration of three objective parameters, was noted in 12 A (67%), 13 B (59%), and 12 C (55%) subjects (C vs. A, P = 0.007). Ophthalmic symptoms and signs regressed most in group A; changes in lid fissure width were -1.5, -0.5, and 0 mm in the A, B, and C groups, respectively (A vs. C, P = 0.005), whereas changes in intraocular pressure (upgaze) were -3, +1, and -1.5 mm Hg, respectively (A vs. B, P = 0.002). The median decreases in proptosis were -2 mm (A, P = 0.0001), -1.5 mm (B, P = 0.02), and -1 mm (C, P = 0.007; A vs. C, P = 0.0380. Visual acuity (+0.15; P = 0.02) and eye muscle motility (bulbar elevation, 30 degrees vs. 37 degrees, P = 0.03, A vs. C, P = 0.0020; abduction, 45 vs. 49 degrees, P = 0.02; A vs. C, P = 0.017) improved in group A only. A significant change in all rectus muscle areas was noted in 14 A (78%), 12 B (55%), and 9 C (41%) subjects (C vs. A, P = 0.002). A decrease in the NOSPECS classes was observed in 12 A (67%), 13 B (59%), and 13 C (59%) patients (A vs. B/C, P = 0.01). Rx-induced conjunctivitis was not observed in group A, but was seen in 4 B (18%) and 8 C (36%) subjects (C vs. A, P = 0.003). At 24 weeks, satisfaction rates were 67%, 59%, and 55% in the A, B, and C groups, respectively (C vs. A, P = 0.008). Thus, in patients with moderately severe GO, similar response rates were observed for low and high Rx doses, but the 1 Gy/week protocol was more effective and better tolerated than the short arm regimens.

Five-year experience with combined operative and radiotherapeutic treatment of recurrent gynecologic tumors infiltrating the pelvic wall.

BACKGROUND: Whereas 25 to 50% of selected patients with gynecologic tumors who relapse centrally in an irradiated pelvis can be salvaged by exenteration, postirradiation recurrence infiltrating the pelvic side wall generally has been fatal. We have designed the combined operative and radiotherapeutic treatment (CORT) procedure for the treatment of postirradiation recurrence infiltrating the pelvic wall and developed several new techniques for its realization. The aim of the surgery is as follows: (1) total resection of the tumor with only a microscopic margin (R1) at the pelvic wall, preserving the bony pelvis and the neurovascular support of the leg; (2) modulation of the therapeutic index for a second high-dose irradiation of the pelvic wall by transferring autologous tissue from the abdomen or the thigh, and (3) reconstruction of pelvic organ functions lost due to tumor resection. The tumor bed is irradiated postoperatively with brachytherapy through transcutaneous guide tubes implanted at the pelvic wall. METHODS: Between April 1989 and December 1994, we treated 48 patients with postirradiation recurrent or persistent gynecologic malignancies infiltrating the pelvic wall with CORT and followed them prospectively with the following endpoints: tumor control, survival, complications, and quality of life. RESULTS: At a median follow-up of 33 months (range, 3-71 months), the 5-year survival probability calculated with the Kaplan-Meier method was 44%. The overall local control rate was 68%, and 85% in the last 25 patients in the series. The censored severe complication rate at 5 years was 33%. No patient died as a consequence of the treatment. Quality of life was self-assessed with a validated questionnaire by 15 patients without evidence of disease, and was rated with a total of 74% of the maximum score points. Age of the patient, state of resection at the pelvic wall (R1 vs. R2), and recurrent tumor size independently influenced tumor progression after CORT in this series. CONCLUSIONS: CORT appears to be a feasible, innovative treatment with long term survival potential and acceptable quality of life for selected patients with postirradiation gynecologic tumor recurrence infiltrating the pelvic wall. R1 resection of the tumor at the pelvic wall is mandatory; however, the reconstruction options within the pelvis are limited.

[The palliative radiotherapy of Kaposi's sarcomas in AIDS patients]. / Palliative Strahlentherapie von Kaposi-Sarkomen bei Patienten mit AIDS.

BACKGROUND: Follow-up of patients, who were irradiated because of AIDS-related Kaposi's sarcomas. PATIENTS AND METHODS: From 1983 to 1994 17 patients were irradiated because they suffered from AIDS-related neoplasms. Fifteen of these were irradiated because of Kaposi's sarcomas. The radiation fields were as small as possible, the total dose that was given was 30 Gy in the average, given 5 x 2 Gy or 4 x 2.5 Gy per week. RESULTS: The results concerning the cosmetic benefits were good, the pain could be reduced very well. In two patients the radiation therapy was cancelled: 1 patient suffered from a general tumor progression and 1 did not allow any further therapy. The remission rate was 3 to 4 months in the average, 3 patients did not show local progression for 4 respectively, 5 months now. One patient was in remission for 8 months. CONCLUSIONS: The radiation therapy is a local, but very effective method to treat patients with AIDS-related Kaposi's sarcomas. Whereas the side-effects are very little, we found quite a long remission rate.

[Combined surgical and radiotherapeutic treatment of pelvic wall recurrences: report of experiences after 3 years]. / Die kombinierte operative und radiotherapeutische Behandlung (CORT) von Beckenwandrezidiven: Erfahrungsbericht nach 3 Jahren.

CORT has been developed to treat recurrent gynaecological malignancies infiltrating the pelvic wall unilaterally. The surgical part consists of: (i) staging laparotomy/lymphadenectomy, (ii) maximum tumour resection at the pelvic wall and exenteration of infiltrated central pelvic organs, (iii) implantation of guiding tubes on the residual tumour/tumour bed on the pelvic wall, (iv) pelvic wall plasty with muscle, musculocutaneous and omentum flaps, (v) operative reconstruction of bowel, bladder and perineo-vulvo-vaginal functions. Radiation is performed as interstitial high dose rate brachytherapy through the implanted tubes. Patients without prior pelvic irradiation receive in addition, whole pelvis teletherapy. CORT has been evaluated in a prospective phase I and II trial at the University of Mainz. Within a 3-year period, 21 patients with pelvic wall recurrences from various gynaecological primary tumours were treated. Seventeen patients had been irradiated as (part of) the previous therapy with a median total mid-pelvic dose of 65 Gy (range 40-100 Gy). There was no operative mortality. Five patients developed complications necessitating surgical intervention. One patient died from fatal thromboembolism 6 months after CORT without evidence of tumour progression. In 14 patients, local tumour control has been achieved. After a median follow-up period of 27 months (range 6-38 months) Kaplan-Meier life table analysis revealed an actuarial survival probability of 55% (recurrence-free 49%). We conclude from these preliminary results, that the CORT procedure for the treatment of pelvic wall recurrences is feasible and may lead to encouraging therapeutic success in selected patients, whose situation had been hopeless so far.

[Radiotherapy in scar-induced keloid]. / Strahlentherapie beim Narbenkeloid.

AIMS: In a retrospective study, the results of the excision of keloids in combination with postoperative irradiation were investigated with respect to the cosmetic effect and the recurrence rate. PATIENTS: Between 1978 and 1990, 20 patients aged between 15 and 64 years who, together, had a total of 23 localized keloids, were submitted to prophylactic irradiation following excision of the latter. TREATMENT: Radiotherapy was applied, fractionated, using low-energy (soft) X-rays, the strontium 90 Dermaplatte, or with electrons produced by a linear accelerator. The mean total surface dose applied was 20 Gy. RESULTS: Eighteen patients with 21 keloids were followed-up for a period of between 2 months and 12 years (mean: 33 months). The cosmetic result was good or very good in 17, and unsatisfactory in four of the 21 keloids. Prior to treatment, 18 of the keloids were associated with local complaints; 15 of these cases were symptom-free after treatment. CONCLUSION: With the combination of excision and postoperative irradiation, the results of keloid treatment can be improved, and recurrence largely avoided.

[The percutaneous irradiation of osteolytic bone metastases--a course assessment]. / Perkutane Radiatio osteolytischer Knochenmetastasen--eine Verlaufsbeurteilung.

Percutaneous radiotherapy is the most effective modality for treatment of metastatic bone cancer. Local irradiation improves overall quality of life by relieving pain in most patients. It also helps preventing complications as pathological fractures in lytic bone lesions by new bone formation. In a retrospective study on 100 patients, irradiated for lytic bone metastases, the radiotherapeutic effect on alleviation of pain and on recalcification rate was investigated. In our experience in 84% of the cases pain and disability associated with bone metastases could be decreased. 38% of the patients had complete relief of symptoms. A correlation between subjective therapy effect and histology of the primary tumor was not demonstrated. Remineralization was found in 67% of all irradiated skeletal areas (n = 137) (recalcification rate in breast cancer 77%, in bronchial carcinoma 27%, and in renal cell carcinoma 25%). After a total dose of 30 Gy reduction of the metastases-associated pain was achieved in 81% of the cases and remineralization was observed in 70% of the cases.

[Scintigraphic use of 87Y during 90Y therapy of bone metastases]. / Szintigraphische Verwendung von 87Y bei der 90Y-Therapie von Knochenmetastasen.

Carrier-free 87Y is produced by cyclotron irradiation of Rb. It decays with a half-life of 80.3 h, transforming via 87mSr to stable 87Sr with the emission of gamma lines of 0.48 and 0.39 MeV. Experience in 6 patients shows good scan quality and correspondence between 99mTc-DPD and 87Y images useful in 90Y-citrate therapy for bone metastases. 87Y offers new possibilities of studying biological kinetics in 90Y therapy. To avoid contamination this should only be used in departments with possibilities of radioactive waste storage and controlled disposal.

Graves ophthalmopathy: role of MR imaging in radiation therapy.

Twenty-three patients with Graves ophthalmopathy who underwent radiation therapy were monitored by means of magnetic resonance (MR) imaging. T2 relaxation times of extraocular muscles and orbital fat, areas of extraocular muscles, and degree of exophthalmos were measured by means of MR imaging at the beginning, at the end, and 3 months after completion of radiation therapy. As a result, patients with primarily elevated T2 times of extraocular muscles showed a better therapy response regarding muscle thickening than patients with primarily normal T2 times. Elevated T2 times, which probably represent acute inflammatory changes, were markedly decreased at the end of therapy. Therefore, quantitative MR imaging favors the choice of anti-inflammatory therapy regimens in patients with elevated T2 times of extraocular muscles. However, the clinical response (activity scores) to the low-dose treatment protocol that was used did not correlate well with primarily elevated T2 times. Furthermore, T2 times increased again after cessation of therapy. Whether a higher radiation dose or a different fractionation scheme leads to better results must be clarified by means of further study.

MRI-assisted radiation therapy planning of brain tumors--clinical experiences in 17 patients.

A new and simple method for precise determination of lateral opposed treatment portals was developed and used in 17 patients. Compared to CT, MRI led to significant changes of portals in 59% (10/17) of cases. Individual shielding blocks could be precisely designed by use of our new method. MRI is the procedure of choice in local radiation therapy planning of brain tumors.

[Sonography of bone metastases--its place in comparison with computed tomography and conventional x-ray diagnosis]. / Sonographie bei Skelettmetastasen--Stellenwert im Vergleich zur Computertomographie und konventionellen Röntgendiagnostik.

The value of CT, conventional radiography and ultrasound was compared in 40 patients with 52 skeletal metastases. For superficial lesions, the combination of sonography and conventional radiography was equivalent to CT in showing the extent of bone destruction and soft tissue involvement. As expected sonography was unsatisfactory for deeper lesions. Sonography can provide useful information for planning radiation therapy for superficial lesions, but it does not replace conventional radiography.

[A simple method for MRI-assisted radiotherapy planning in brain tumors]. / Eine einfache Methode zur MRT-gestützten Bestrahlungsplanung von Hirntumoren.

A simple method for radiation therapy planning of brain tumors is presented. Therapy portals of midline tumors can easily be determined by comparing sagittal MRI scans with the lateral simulator radiograph. By addition of appropriately processed MR-tomograms a similar planning is possible for parasagittal tumors. Digital data exchange between different operating systems is not necessary with our simple method, problems with varying input/output standards and expensive hardware requirements are thus avoided.

[Radiotherapy in HIV positive patients]. / Strahlentherapie bei HIV-positiven Patienten.

HIV-positive Patients often suffer from the symptoms of accompanying diseases. Palliative radiation therapy of associated tumors leads to an improvement of the patient's condition. Particularly skin tumors, which give rise to pronounced itching and ulcerating, are eliminated fast and safe by radiation therapy. Between 1984 and 1988, 6 HIV patients with Kaposi's sarcoma at different sites, and one HIV-patient with non-Hodgkin's lymphoma were treated by radiation therapy. Depending on tumor site, photons or fast electrons were used. Cosmetic results were satisfying or even excellent in all patients. With one exception complete local tumor control was obtained. Side effects leading to a peace of treatment did not occur.